Guidelines For Operationalising First Referral Units - National Rural ...

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1.2 Tenth Plan: Recommended approach 1.2.1 The working group on health care for women and children for Tenth Five Year Plan have identified establishment of fully functional and operational FRUs as the priority area for the provision of Emergency Obstetric and New-born Care. The group has recommended as under: "It is imperative that the existing infrastructure and specialist manpower at FRUs/CHCs is looked into critically and re-organized, and mis-matches between infrastructure and manpower corrected. At the first instance it would be desirable to ensure provision of quality Emergency Care Services at least at the district hospital and sub-district hospital followed by FRUs/CHCs. Thus, developing some FRUs in a district by ensuring that they have the required number of specialists in position or have access to the services of specialists on call, would be a preferred option rather than having a number of FRUs which may not be providing full range of services. The information on location of such emergency services/FRUs will be made available to all villages in the area so that the population knows where they should reach for getting appropriate emergency care. The provision of emergency care has also to be supported by appropriate referral services from sub-centers to PHCs and from PHCs to the functioning First Referral Units providing emergency services." 1.2.2 In view of the foregoing, it is considered imperative that the States look at the existing facilities and identify clearly their requirements for putting into place fully functional FRUs. It is envisaged that by the end of the Tenth Five Year Plan, each district should have at least 3-4 fully functional facilities which are equipped to provide the full range of Emergency Obstetric and New-born Care on a round-the-clock basis. 1.2.3 To realize the above objective, an exercise will need to be undertaken for mapping the existing health facilities, available manpower and other resources for each district. This exercise will facilitate proper placement of the available resources and at the same time will bring out additional requirements in terms of training, equipment and infrastructure required for operationalising the identified CHCs/sub-district hospitals as FRUs. To facilitate this exercise, formats have been designed and are given in Annex III {Formats I, II & III}. Based on this exercise, it should be possible to draw the district-wise action plans for operationalising FRUs in a phased manner. Consolidation of the district plans at the state level will thus bring out the overall requirements of the State in various areas, like infrastructure, equipment, manpower and training needs for operationalising FRUs during the Tenth Plan. 1.2.4 The guidelines below are an attempt to facilitate the planning exercise by the States and also take into account the recommendations of the National workshop organized in 1999 for operationalisation of FRUs, in which all the States, donor agencies, experts and programme officers of the Department of Family Welfare participated. 1.2.5 The suggestions/recommendations made below also draw upon two consultative meetings with the States and experts held in connection with the proposed second phase of the RCH programme. provide round-the-clock services for Emergency Obstetric and New-born Care, in addition to all emergencies that any hospital is required to provide (Box-1). Box-1: Minimum services to be provided by a fully functional FRU • 24-hour delivery services including normal and assisted deliveries • Emergency Obstetric Care including surgical interventions like Caesarean Sections(*) and other medical interventions • New-born Care(*) • Emergency Care of sick children • Full range of family planning services including Laproscopic Services • Safe Abortion Services • Treatment of STI / RTI • Blood Storage Facility (*) • Essential Laboratory Services • Referral (transport) Services (*): Critical determinants of functionality 2.1.2 It should be noted that there are three critical determinants of a facility being 'declared' as a FRU: availability of Surgical Interventions, New-born Care and Blood Storage Facility on a 24-hour basis. 2.1.3 The planning effort in relation to operationalising the FRUs, therefore, has to focus on carefully selecting such existing CHW/Sub-district hospitals which can be quickly equipped to handle all obstetric emergencies including those requiring surgical interventions like the Caesarean Section. 2.1.4 It may also be noted that the above critical interventions may currently not be available even in some district headquarter hospitals, particularly in the newly created districts in the EAG States. Therefore, the operationalisation effort must be carefully sequenced, and should start by making the district hospital fully operational as a First Referral Unit. 2.1.5 Given the scarcity of resources, particularly the specialists, even the best endowed States have carefully avoided a normative approach (e.g. of declaring all CHCs as FRUs). For example, Maharashtra carried out a detailed assessment exercise covering all CHCs which revealed that it would not be feasible to provide the 24-hour surgical interventions at all CHCs. The State, therefore, selected 3-4 CHCs in every district for provision of FRU services. For the remaining CHCs, the service package has been defined at a lower level of competence. Points to be considered while selecting the facility Critical determinants of a First Referral Unit 2.1 Recommended service package 2.1.1 An existing facility (district hospital, sub-divisional hospital, community health centre etc.) can be declared a fully operational First Referral Unit (FRU) only if it is equipped to Points to be considered while selecting sites for opertionalising FRU services 3.1 Infrastructure needs 3.1.1 To be able to perform the full range of FRU functions, a health facility must have the following physical infrastructure: This may call for selecting a smaller facility in preference to some otherwise 'larger' facilities. For example, a brand new CHC may have to be ignored because it may be too close to the district headquarter or it may be difficult to retain its manpower because of its location. - 2 - - 3 -
• A minimum bed strength of 20-30. However, in difficult areas as the North-East States and the under-served areas in the EAG States, this could be relaxed to 10-12 beds initially. • A fully functional operation theatre equipped for undertaking anaesthetic and emergency surgical procedures including Caesarean Sections and Laporotomies. • A fully operational Labour Room. • An area earmarked and equipped for New-born Care in the Labour Room and also in the ward. • A functional laboratory with facilities for all essential investigations. • Blood storage facility as per the guidelines issued by Govt. of India (GoI). • 24-hour water supply. • Arrangements for waste disposal. • Regular electricity supply with back-up arrangements to ensure uninterrupted supply to the operation theatre and labour room, cold chain and blood storage facility. • Telephone connection. • Ambulance (owned or arranged through local hiring). 3.2 Selection of sites 3.2.1 Under the RCH Programme funds were provided for civil works related to operationalisation of operation theatre, labour rooms and provision of regular water supply etc. at the CHCs and district hospitals. Similarly, civil works have been undertaken at many sub-district facilities as part of the Health Systems Projects in the concerned States. It is expected, therefore, that the physical infrastructure is already in place in many sub-district health facilities in every district. This should be taken into account while carrying out the selection process. 3.2.2.However, situations could arise where the previous investments for infrastructure strengthening may not have been made in facilities which are otherwise optimally located and are more likely to attract specialised manpower than the facilities which were not taken up for such strengthening. For example, investments made to upgrade a CHC located within a few kilometers of the district hospital may not lead to much improvement in the availability of emergency services because (a) the people are likely to by pass it and go to the district hospital and (b) the staff posted at such facility would tend to stay in the district headquarter. 3.2.3 The objective of ensuring proper selection should be to develop a network of 3-4 facilities in the district in such a way that these together with the district hospital can ensure that all emergency cases in the district can access the nearest facility within a maximum travel time of 1 hour. Equipment: Review past receipts 4.1 Twelve types of equipment kits (Kit-E to Kit-P) were designed under the CSSM programme (See Box-2 below) and supplied to the States. Detailed facility surveys carried out in some places have indicated that substantial part of these supplies may still be lying unused in some CHCs which do not have the requisite physical infrastructure and/or the necessary human resources for utilizing the equipment. Some equipment for blood storage have also been supplied under the Aids Control Programme by NACO to a number of subdistrict facilities. Similarly, States covered under the Health Systems Projects have also procured and supplied equipment for the district and sub-district level facilities. Box-2: Equipment kits supplied under CSSM Programme Kit-E: Standard Surgical Set-I (instruments) FRU Kit-F: CHC Standard Surgical Set-II Kit-G: IUD Insertion Kit Kit-H: CHC Standard Surgical Set-III Kit-I: Normal Delivery Kit Kit-J: Standard Surgical Set IV Kit-K: Standard Surgical Set-V Kit-L: Standard Surgical Set VI Kit-M: Equipment for Anaesthesia Kit-N: Equipment for Neo-natal Resuscitation Kit-O: Equipment for Laboratory Tests and Blood Transfusion Kit-P: Materials Kit for Blood Transfusion 4.2 It is clear that an assessment needs to be carried out as part of the process of operationalising FRUs so that the equipment already available in a given district can be taken into account while determining the requirement of equipment. A stock taking at the district level will thus be a necessary exercise and will facilitate shifting of the equipment lying un-utilized at some facilities to those facilities where these may be required. Details of the various equipment kits is in Annexure IV. Human resources: Re-deployment and multi-skilling 5.1 Policy options for human resource management 5.1.1 The community health center was envisaged to be a fully functional FRU (defined to mean a facility providing full range of FRU services including C-section, along with facilities for handling other medical emergencies) and, accordingly, a minimum strength of 4 medical officers (who are either qualified or especially trained to work as surgeon, obstetrician, physician and pediatrician) was recommended. Facilities selected for operationalising FRU services should, therefore, aim to provide a similar or increased strength of medical personnel. In addition, adequate number of nursing staff to work in Operation Theatre, Labour Room and In-patient wards will also need to be carefully determined. 5.2 Re-deployment & multi-skilling 5.2.1 Re-deployment of the resources existing within the districts is one of the important step. This has been gainfully done in West Bengal. Based on a review, the State Government of West Bengal announced an infrastructure rationalization and manpower redeployment policy with a view to improve institutional care in the State. The key features of the policy announcement are as follows: • Strengthening of Block PHCs (BPHCs) and PHCs will be done in a need based manner after actual assessment for each individual institution. This would include rehabilitation of the buildings, provision of new equipment as well as posting of additional manpower. • All the block PHCs shall have minimum 30 indoor beds with complete facilities for institutional delivery and usual indoor treatment care. • Efforts will be made to provide same facilities in the BPHCs as are available in rural - 4 - - 5 -
Page 1 and 2: Guidelines For Operationalising Fir
Page 3 and 4: Preface Reduction in maternal morta
Page 5: Introduction 1.1 Historical backgro
Page 9 and 10: Annexure - I Annexure - II Number o
Page 11 and 12: Annexure - III Annexure - III Forma
Page 13 and 14: Annexure - III Annexure - IV Format
Page 15 and 16: Annexure - IV Annexure - IV Details
Page 17 and 18: Annexure - IV Annexure - IV Details
Page 19: Annexure - IV Details of Equipment

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